Unit 4 NCLEX

A, B, C, D, and E

A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 150 mEq/L (150 mmol/L). Which interventions would the primary health care provider likely prescribe? Select all that apply. A. Monitor vital signs B. Monitor electrolyte levels C. Monitor intake and output D. Increase water intake daily E. Maintain sodium-reduced diet F. Administer hypertonic saline intravenously

A, B, C, D, E

A client enters the emergency department confused, twitching, and having seizures. Upon assessment, flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor is noted. The serum sodium level is 172 mEq/L (172 mmol/L). Which interventions should the primary health care provider (PHCP) likely prescribe? Select all that apply. A. Monitor vital signs B. Monitor intake and output C. Increase water intake orally D. Monitor electrolyte levels E. Provide a sodium-reduced diet F. Administer sodium replacements

A, C, and E

A client has a nasogastric tube in place that is attached to suction. The client is at risk for developing which electrolyte imbalances with prolonged suction? Select all that apply. A. Hypokalemia B. Hyperkalemia C. Hyponatremia D. Hypernatremia E. Hypomagnesemia F. Hypermagnesemia

B and D

A client has a serum sodium level of 129 mEq/L (129 mmol/L) because of hypervolemia. The nurse anticipates the primary health care provider to prescribe which measures? Select all that apply. A. Make the client NPO B. Restrict fluid intake C. Provide a 4 g sodium diet D. Monitor electrolytes every 24 hours E. Prescribe salt, 1 g, orally twice a day F. Administer intravenous hypertonic saline

B, C, and D

A client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client and determines which symptoms correlate with this client's fluid imbalance? Select all that apply. A. Lung crackles B. Flat neck veins C. Weakly palpable peripheral pulses D. Heart rate of 104 beats per minute E. BP of 136/86

Take 2 hours before meals

Etidronate, an antihypercalcemic medication, is prescribed for a client. Which information should the nurse reinforce when instructing the client about taking this medication? A. Take with milk B. Take with meals C. Take with an antacid D. Take 2 hours before meals

Calcitonin

The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL (3.25 mmol/L). Which prescribed medication should the nurse plan to assist in administering to the client? A. Calcitonin B. Calcium chloride C. Calcium gluconate D. Large doses of vitamin D

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional sign/symptom should the nurse expect to note in this client if hyponatremia is present?

Postural blood pressure changes

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for fluid volume deficit?

The client with a ileostomy

A, B, and E

The nurse is caring for a group of clients on a clinical nursing unit. The nurse checks for signs of deficient fluid volume. Which clients are at risk for this fluid imbalance? Select all that apply. A. A client with pneumonia B. A client with an ileostomy C. A client with heart failure D. A client with acute kidney injury E. A client with a temperature of 102.5 F

Butter

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food item is least likely to contain calcium? A. Milk B. Butter C. Spinach D. Collard greens

An increase in blood pressure

The nurse who is caring for a client with kidney failure notes that the client is dyspneic and crackles are heard when listening to breath sounds in the lungs. Which additional sign/symptom should the nurse expect to note in this client? A. Rapid Weight loss B. Flat hand and neck veins C. A weak and thready pulse D. An increase in blood pressure

E and F

The nursing instructor asks the student to describe isotonic dehydration. The student correctly responds by stating which pathophysiological processes are occurring? Select all that apply. A. "The loss of electrolytes is greater than the loss of water." B. "The loss of water is greater than the loss of electrolytes." C. "Serum sodium level rises above 150 mEq/L (150 mmol/L)." D. "The client is likely to have impaired mental status due to low sodium levels." E. "Water and electrolytes are lost in approximately the same proportion as they exist in the body." F. "A client who has a large blood loss due to an accident will initially have an isotonic dehydration."

U Waves

Which electrocardiogram changes would the nurse note on the cardiac monitor with a client whose potassium (K+) level is 2.7 mEq/L (2.7 mmol/L)? A. U waves B. Flat P waves C. Elevated T waves D. Prolonged PR intervals

A and B

Which fluids are identified as insensible fluid losses? Select all that apply. A. Sweat B. Sputum C. Nasogastric tube output D. Output from Jackson-Pratt drain E. Urine output from indwelling catheter

A, B, and C

A primary health care provider (PHCP) has written a prescription for calcium carbonate for the client with hypocalcemia. The nurse is reinforcing teaching with the client and should include which instructions? Select all that apply. A. Take the calcium carbonate with or just after meals B. Avoid foods such as beets, spinach, and bran in the diet C. Take the medication with a full glass of water (8 oz/ 240 mL) D. It is permissible to swallow whole and not chew the chewable tablets E. It is permissible to take an extra calcium pill if the client develops tremors

B, C, and E

The nurse is told in a report that the client has hypocalcemia. Which signs should the nurse expect to note during the data collection? Select all that apply. A. Coma B. Tetany C. A positive Chcostek's sign D. Hypoactive bowel sounds E. A positive Trousseau's sign

B, C, and F

A 0.9% intravenous (IV) solution is prescribed for a client. The IV is to run at 100 mL/hr. The nurse prepares the solution, understanding that which are characteristics of this type of solution? Select all that apply. A. Affects the plasma osmolarity B. Is the same solution as sodium chloride 0.9% C. Is used to administer red blood cell transfusion D. Is hypotonic with plasma and other body fluids E. Is hypertonic with the plasma and other body fluids F. Is used to treat hypotension due to fluid volume deficit

C and D

A client has been admitted to the hospital with a diagnosis of severe nausea and vomiting. The client has an indwelling intravenous (IV) catheter. The client's morning laboratory results show a serum blood sodium level of 130 mEq/L (130 mmol/L) and a serum blood chloride level of 92 mEq/L (92 mmol/L). Which intravenous fluids should provide free water, sodium, and chloride to the client? Select all that apply. A. Lactated Ringer's solution B. 0.9% sodium chloride in water solution C. 0.45% sodium chloride in water solution D. Dextrose 5% in 0.225% sodium chloride solution E. Dextrose 5% in lactated Ringer's solution

A, D, E, and F

The metabolic panel of a client reveals a calcium level of 6.5 mg/dL (1.6 mmol/L). Based on this laboratory finding, which additional data specific to this calcium level should the nurse collect? Select all that apply. A. Presence of Chvostek's sign B. Presence of muscle weakness C. Presence of decreased deep tendon reflexes D. Presence of electrocardiogram abnormalities E. Presence of tingling in the fingertips and around the mouth F. Presence of carpal spasm when blood pressure cuff is inflated above systolic blood pressure for a few minutes

Hypercalcemia

The nurse admits a client with a diagnosis of dehydration and a positive history of cancer to the nursing unit. The client is extremely weak and has an irregular heart pulse rhythm. There are absent bowel sounds, and the client's last bowel movement was 4 days earlier. The nurse plans to review serum electrolyte levels because the client is at high risk for which electrolyte imbalance? A. Hyponatremia B. Hypercalcemia C. Hypocalcemia D. Hypomagnesemia

Muscle weakness

The nurse is assisting in caring for a client who is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The nurse is monitoring the client for signs of hyperkalemia. Which sign/symptom should be noted in the client if hyperkalemia is present? A. Muscle pain B. Mental confusion C. Muscle weakness D. Depressed deep tendon reflexes

Administer hypertonic normal saline solution intravenously

The nurse is assisting in caring for a client with severe hyponatremia resulting from hypervolemia. The nurse anticipates which treatment would be prescribed by the primary health care provider? A. Administer a blood transfusion B. Force oral fluid intake to 2000 mL per day C. Include foods high in potassium in the diet. D. Administer hypertonic normal saline solution intravenously

C, D, and E

The nurse is assisting in the care of a client who has a serum sodium level of 128 mEq/L (128 mmol/L). The nurse relates which of the client's signs and symptoms to this electrolyte imbalance? Select all that apply. A. Dry flaky skin B. Bleeding from the gums C. Weakness in all extremities D. Confusion with garbled speech E. Diarrhea with abdominal cramping

Left foot has 4+ pitting edema

The nurse is assisting in the care of a client with a left foot that sustained a crush injury. The nurse determines that the client developed third spacing of body fluid based on which observation? A. Blood pressure is 138/74 B. Left foot has 4+ pitting edema C. Skin instantly returns to position after being pinched up D. Abdomen is slightly distended with active bowel sounds

B and E

The nurse is assisting in the care of a client with a new ileostomy on the clinical nursing unit. Which observations indicate to the nurse that the client is at risk for fluid volume deficit? Select all that apply. A. Pulse oximetry reading 92% B. Ileostomy output of 650 mL in 4 hours C. Skin returns to position after being pinched up D. Fine inspiratory crackles that clear with coughing E. BP 104/66, temp 98.4 F, pulse 106 beats per min, respirations 20 breaths a min

Monitoring for decreased urine output and hypotension

The nurse is monitoring the fluid balance of a client with advanced human immunodeficiency virus (HIV) infection. Because the client has lost a great deal of weight and muscle mass, the nurse understands that which action will provide a reliable indicator of fluid balance? A. Checking for moistness of the skin B. Checking for skin turgor with tenting C. Monitoring for decreased urine output and hypotension D. Precisely measuring vomitus and diarrhea

B and D

The nurse is obtaining the report for a group of assigned clients. The nurse plans to monitor the serum potassium levels in which clients at risk for hyperkalemia? Select all that apply. A. A client with ulcerative colitis B. A client with a new burn injury C. A client with Cushing's syndrome D. A client diagnosed with acute kidney injury E. A client who has a history of long-term laxative abuse

B and E

The nurse is reviewing the health care records of assigned clients. Which clients are at highest risk for excess fluid volume? Select all that apply. A. The client on diuretics B. The client with renal failure C. The client with ileostomy D. The client on gastrointestinal (GI) suctioning E. The client with chronic CHF

The client with a fast respiratory rate

The nurse is reading the primary health care provider's (PHCP's) progress notes in the client's record and sees that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss? A. The client with a draining wound B. The client with a urinary catheter C. The client with a fast respiratory rate D. The client with a nasogastric tube to low suction

The client receiving nasogastric suction

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit? A. The client with Addison's disease B. The client with metabolic acidosis C. The client with intestinal obstruction D. The client receiving nasogastric suction

The client with diabetes mellitus

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the least likely risk for the development of third-spacing? A. The client with sepsis B. The client with cirrhosis C. The client with kidney failure D. The client with diabetes mellitus

Vitamin D

A client undergoing renal dialysis is prescribed calcitriol to treat hypocalcemia. The nurse reinforces instructions and informs the client that this medication is also known as which nutrient? A. Vitamin C B. Vitamin D C. Complete protein D. Low saturated fat

C and E

A client is at risk for developing hypocalcemia. The nurse determines which signs are associated with this electrolyte disturbance? Select all that apply. A. Increased heart rate B. Increased blood pressure C. Positive Trousseau's sign D. Hypoactive bowel sounds E. Fine tremors noted in hands

2520 mL

The nurse is calculating a client's 24-hour fluid intake. The client consumed coffee (8 oz), water (8 oz), and orange juice (6 oz) for breakfast; soup (4 oz) and iced tea (8 oz) for lunch; and milk (10 oz), tea (8 oz), and water (8 oz) for dinner. The client also consumed 24 oz of water during the day. How many milliliters of fluid did the client consume in the 24-hour period? Fill in the blank.

Increased specific gravity of the urine

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding should the nurse expect to note as a result of this long-term use? A. Gurgling respiration B. Increased blood pressure C. Decreased hematocrit level D. Increased specific gravity of the urine

Traumatic Burn

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L (5.5 mmol/L). The nurse understands that a potassium value at this level would be noted with which condition? A. Diarrhea B. Traumatic burn C. Cushing's Syndrome D. Overuse of laxatives

Obtain orthostatic vital signs

A client presents in the emergency department reporting severe nausea, vomiting, and diarrhea for 5 days. The client is weak, has 2+ tenting skin turgor, and states a weight loss of 7 pounds in the last week. At this time, which action would the nurse take? A. Obtain orthostatic vital signs B. Prepare to insert a nasogastric tube feeding C. Prepare to insert a parenteral nutrition infusion D. Check the client's skin for irritation caused by diarrhea

Inform the RN of the lab value

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed and the serum calcium level is 12.0 mg/dL (3.0 mmol/L). Based on this laboratory value, the nurse should take which action? A. Document the value in the client's record. B. Inform the RN of the lab value C. Place the lab result form in the client's record D. Reassure the client that the lab result is normal

The client with the syndrome of inappropriate secretion of anti diuretic hormone

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L (130 mmol/L). The nurse expects that this sodium level would be noted in a client with which condition? A. The client with watery diarrhea B. The client with diabetes insipidus C. The client with an inadequate daily water intake D. The client with the syndrome of inappropriate secretion of anti diuretic hormone

Prolonged bed rest

The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL (2.0 mmol/L). The nurse understands that which condition would cause this serum calcium level? A. Prolonged bed rest B. Adrenal insufficiency C. Hyperparathyroidism D. Excessive ingestion of vitamin D

A, B, C, E

Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply. A. A premature infant B. A 101-year-old man C. A client with heart failure D. A client with diabetes mellitus E. A client receiving renal dialysis F. A 29-year-old client with pneumonia

A and E

The nurse is reviewing the laboratory results of a client hospitalized with a diagnosis of Crohn's disease. The client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which nursing interventions should the nurse initiate? Select all that apply. A. Monitor the client for dysrhythmias B. Instruct the client to consume low-calcium foods C. Instruct the client to include a banana in the daily diet D. Instruct the client to consume foods low in magnesium E. Notify the PCP of the lab results

B and D

The nurse is caring for a client with a nasogastric tube in place for gastric decompression. The primary health care provider (PHCP) prescribes to have the tube irrigated once every 8 hours. Select the correct interventions the nurse should utilize in performing this procedure. Select all that apply. A. Follow strict sterile technique B. Utilize 30 mL of 0.9% normal saline for the irrigating solution C. Inject the irrigating solution through the air vent of the Salem sump tube D. After injecting the irrigating solution, pull back on the irrigation syringe E. Check client's electrolyte lab results to determine correct irrigating solution

B and D

The nurse is caring for a client with cirrhosis who is experiencing fluid overload. The nurse would determine that this problem is resolving if which data are obtained? Select all that apply. A. Increasing pulse B. Decreasing body weight C. Decreasing urine output D. Decreasing abdominal girth E. Increasing central venous pressure

A and C

The nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which assigned clients are at risk for excess fluid volume? Select all that apply. A. The client with renal failure B. The client with an ileostomy C. The client with chronic cirrhosis D. The client with a draining abdominal wound E. The client with a nasogastric tube to low suction

Hypertension

The nurse is assigned to care for a group of clients on the clinical nursing unit. Which client is least likely to develop third spacing of fluids? A. Major burn B. Renal failure C. Hypertension D. Laennec's cirrhosis

The skin when pinched immediately fell back to normal when released

The nurse checks a client's skin turgor and documents that the client exhibits normal fluid balance. Which statement correctly describes what the nurse has documented? A. The skin when pinched remained elevated when released B. The skin when pinched failed to return to normal when released C. The skin when pinched immediately fell back to normal when released D. The skin when pinched remained tented for several seconds when released

A client with a history of alcoholism

The nurse is caring for a group of clients. Which client is most likely to have a serum phosphorus level of 2.0 mg/dL (0.64 mmol/L)? A. A client receiving chemotherapy B. A client with hypoparathyroidism C. A client with a history of alcoholism D. A client admitted with vitamin D intoxication

B, D, and E

The nurse is planning to reinforce dietary teaching about following a diet that is low in potassium to a client receiving a potassium-retaining (sparing) diuretic. The nurse should be sure to include which strategies to avoid foods high in potassium in the diet? Select all that apply. A. Dried fruits are good for snacks B. Use eggs as a source of protein C. Limit cereals and bread products D. Avoid eating lunch meats and bologna E. Eat salads with cabbage and lettuce and avoid spinach

Narrow, peaked T waves

The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L (5.4 mmol/L). What should the nurse look for on the cardiac monitor as a result of this laboratory value? A. ST elevation B. Peaked P waves C. Prominent U waves D. Narrow, peaked T waves

C and E

The nurse reviews an assigned client's laboratory report and notes a serum potassium level of 5.5 mEq/L (5.5 mmol/L). The nurse should determine that this is an expected finding if the client had which health problems? Select all that apply. A. Diarrhea B. Ulcerative colitis C. Severe burn injury D. Cushing's syndrome E. Untreated ketoacidosis

Generalized muscle weakness

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom would be an indication of this electrolyte imbalance? A. Twitching B. Positive Trousseau's sign C. Hyperactive bowel sounds D. Generalized muscle weakness

D and F

The nurse is caring for a client whose magnesium level is 3 mEq/L (1.5 mmol/L) and the client is being treated for the magnesium imbalance. The nurse interprets that the electrolyte imbalance is resolving if which signs or symptoms are no longer present? Select all that apply. A. Tetany B. Twitches C. Chest pain D. Hypotension E. Muscular excitability F. Loss of deep tendon reflexes